Get Canarx Enrollment Form

Completing the Canarx Enrollment Form online is a straightforward process designed to assist users in accessing necessary medications at low costs. This guide will provide you with clear instructions to ensure that your enrollment is accurate and efficient.

Follow the steps to successfully complete your enrollment form:

1. Press the ‘Get Form’ button to access the enrollment form and open it to begin filling out your details.
2. Fill in your Tufts member ID number at the top of the form, if applicable.
3. Complete the 'Patient Information' section by entering your birthdate, last name, first name, and initial. Indicate whether you are the subscriber, spouse, or dependent. Provide your contact numbers for work/cell and home.
4. Detail your street address, city, state, and zip code in the corresponding fields.
5. List all current medications, including prescription, non-prescription, over-the-counter, herbal, nutritional, and vitamin supplements. For each medication, provide the name, dosage, frequency of intake, start date, and the reason for taking it.
6. Complete the 'Medical History' section by summarizing any operations, hospitalizations, present illnesses, and drug allergies, if applicable.
7. If the patient is a dependent child under 18, have the parent or guardian sign and date the authorization section.
8. If the patient is the subscriber, spouse, or a dependent child aged 18 and over, the patient must sign and date the authorization section.
9. Review the 'Terms of Agreement' carefully and confirm your understanding before providing consent.
10. Once all sections are filled out, you have the option to save your changes, download, print, or share the completed form as needed.

Complete your Canarx Enrollment Form online today to access your needed medications.